A case of imported Leishmania infantum cutaneous leishmaniasis; an unusual presentation occurring 19 years after travel

BACKGROUND: Leishmania infantum is a flagellated protozoan parasite that is able to parasitize blood and tissue. Leishmania species cause a spectrum of clinical disease with cutaneous, visceral or mucosal involvement. L. infantum is recognised as a cause of visceral leishmaniasis (VL) and is less commonly reported as a cause of cutaneous leishmaniasis (CL) from countries around the Mediterranean basin. This is the first report of imported L. infantum CL to Australia and is remarkable for a 19 year period between the patient's exposure to an endemic region, and the manifestation of symptoms. CASE PRESENTATION: A 76 year old Italian-born man presented to our institution with a non-healing lesion over his upper lip, abutting his nasal mucosa. The patient had travelled to Italy, an endemic area for L. infantum 19 years earlier but had resided in Australia, a non-endemic area since. Histopathology performed on a biopsy of the lesion demonstrated findings consistent with CL. A species specific polymerase chain reaction (PCR) performed on the tissue detected L. infantum. The patient had complete clinical recovery following treatment with Liposomal amphotericin B at a dose of 3 mg/kg for five days followed by a subsequent 3 mg/kg dose at day ten. CONCLUSIONS: L. infantum should be recognised as a cause of imported CL in returned travellers from the Mediterranean. In this case, the incubation period for L. infantum CL was at least 19 years. This case adds to the described spectrum of clinical presentations of leishmaniasis and supports the theory of parasite persistence underlying natural immunity and recurrence of disease. Clinicians should consider L. infantum CL in the differential diagnosis of a non-healing skin lesion in any patient who reports travel to the Mediterranean, even when travel occurred several years before clinical presentation

A physician targeted intervention improves prescribing in chronic heart failure in general medical units

Abstract Background Despite strong evidence for beta-blockers and angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) in chronic heart failure (CHF), they have been under-utilised especially in general medical units. We aim to evaluate the effectiveness and feasibility of a physician-targeted quality improvement intervention with education and feedback on the prescription of beta-blockers and ACEI/ARB for CHF management in an inpatient setting. Methods We conducted an interrupted time series study between January 2009 and February 2012. A two-stage intervention was implemented. Between November 2009 and January 2011, a structured physician-oriented education program was undertaken. From February 2011, quarterly performance feedback was provided to each medical unit by a senior clinician. Medical notes of patients admitted with CHF under general medical units before and during the intervention were prospectively audited. Main outcomes were beta-blockers and ACEI/ARB prescription rates, and 180-day readmission rates for CHF. Results Four hundred and sixty-eight patients were included in this study. Structured education program was associated with a significant rise in beta-blockers prescription rates from a baseline of 60 to 92% (p = 0.003), but a non-sustained rise in ACEI/ARB prescription. Regular performance feedback resulted in a further sustained increase in ACEI/ARB prescription rates from 62 to 93% (p = 0.028) and a positive trend for beta-blockers with rates maintained at 89%. There was a reduction in 180-day readmission rates that correlated with the improvements in beta-blocker (p = 0.030) and ACEI/ARB (p = 0.035) prescription. Conclusion Implementation of a structured education program with regular performance feedback was durable and was associated with improvements in appropriate prescribing and an observed decrease in CHF-related readmissions

Murray Valley encephalitis: a review of clinical features, diagnosis and treatment

Murray Valley encephalitis virus (MVEV) is a mosquito-borne virus that is found across Australia, Papua New Guinea and Irian Jaya. MVEV is endemic to northern Australia and causes occasional outbreaks across south-eastern Australia. 2011 saw a dramatic increase in MVEV activity in endemic regions and the re-emergence of MVEV in south-eastern Australia. This followed significant regional flooding and increased numbers of the main mosquito vector, Culex annulirostris, and was evident from the widespread seroconversion of sentinel chickens, fatalities among horses and several cases in humans, resulting in least three deaths. The last major outbreak in Australia was in 1974, during which 58 cases were identified and the mortality rate was about 20%. With the potential for a further outbreak of MVEV in the 2011–2012 summer and following autumn, we highlight the importance of this disease, its clinical characteristics and radiological and laboratory features. We present a suspected but unproven case of MVEV infection to illustrate some of the challenges in clinical management. It remains difficult to establish an early diagnosis of MVEV infection, and there is a lack of proven therapeutic options

How to Handle Concomitant Asymptomatic Prosthetic Joints During an Episode of Hematogenous Periprosthetic Joint Infection, a Multicenter Analysis

[Background] Prosthetic joints are at risk of becoming infected during an episode of bacteremia, especially during Staphylocococcus aureus bacteremia. However, it is unclear how often asymptomatic periprosthetic joint infection (PJI) occurs, and whether additional diagnostics should be considered.[Methods] In this multicenter study, we retrospectively analyzed a cohort of patients with a late acute (hematogenous) PJI between 2005–2015 who had concomitant prosthetic joints in situ. Patients without at least 1 year of follow-up were excluded.[Results] We included 91 patients with a hematogenous PJI and 108 concomitant prosthetic joints. The incident PJI was most frequently caused by Staphylococcus aureus (43%), followed by streptococci (26%) and Gram-negative rods (18%). Of 108 concomitant prosthetic joints, 13 were symptomatic, of which 10 were subsequently diagnosed as a second PJI. Of the 95 asymptomatic prosthetic joints, 1 PJI developed during the follow-up period and was classified as a “missed” PJI at the time of bacteremia with S. aureus (1.1%). Infected prosthetic joints were younger than the noninfected ones in 67% of cases, and prosthetic knees were affected more often than prosthetic hips (78%).[Conclusions] During an episode of hematogenous PJI, concomitant asymptomatic prosthetic joints have a very low risk of being infected, and additional diagnostic work-up for these joints is not necessary.Peer reviewe

Personal Protective Equipment and Antiviral Drug Use during Hospitalization for Suspected Avian or Pandemic Influenza1

In a pandemic, many current national stockpiles of PPE and antiviral medications are likely inadequate

The treatment of prosthetic joint infection with debridement, prosthesis retention and biofilm-active antibiotics

© 2014 Dr. Craig Alexander AboltinsPublications included in thesis:Aboltins, C. A., Page, M. A., Buising, K. L., Jenney, A. W. J., Duffy, J. R., Choong, P. F. M., et al. (2007). Treatment of staphylococcal prosthetic joint infections with debridement, prosthesis retention and oral rifampicin and fusidic acid. Clinical Microbiology and Infection, 13(6), 586-591. DOI: 10.1111/j.1469-0691.2007.01691.xAboltins, C. A., Dowsey, M. M., Buising, K. L., Peel, T. N., Daffy, J. R., Choong, P. F., et al. (2010). Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clinical Microbiology and Infection, 17(6), 862-867. DOI: 10.1111/j.1469-0691.2010.03361.xAboltins, C., Dowsey, M., Peel, T., Lim, W. K., Parikh, S., Stanley, P., et al. (2013). Early prosthetic hip joint infection treated with debridement, prosthesis retention and biofilm-active antibiotics: functional outcomes, quality of life and complications. Internal Medicine Journal, 43(7), 810-815. DOI: 10.1111/imj.12174Background: Prosthetic joint infection (PJI) is a serious infection that is difficult to cure and is associated with significant morbidity. The pathogenesis of PJI involves bacteria growing in biofilm adherent to the prosthesis surface, making them resistant to eradication with standard antibiotics. Recent evidence demonstrates successful treatment of early PJI with surgical debridement and retention of the prosthesis (DAR) and the biofilm-active antibiotic combination of rifampicin and a fluoroquinolone for staphylococcal infections. However, there are few studies investigating appropriate antibiotics to use in combination with rifampicin for PJI caused by staphylococci resistant to fluoroquinolones or which antibiotics to use for organisms other than staphylococci. Little is known about functional outcomes, quality of life (QOL) or complications after treatment of PJI. The aim of this thesis is to provide further evidence to help guide management in these areas. Methods: This thesis synthesizes three of my recent studies published in peer-reviewed journals and one study presented at a national scientific meeting. In the first study, outcomes were analysed for consecutive patients with staphylococcal PJI treated with DAR and a combination of rifampicin and fusidic acid. The second examined consecutive patients with a Gram-negative bacillus PJI treated with DAR and ciprofloxacin-based regimens. In the third study, consecutive patients treated for hip PJI with DAR and biofilm-active antibiotics were matched to controls that had hip arthroplasty with no infection, and their function, QOL and complications compared. In the fourth study, a large prospective hip and knee arthroplasty cohort was analysed to determine if PJI treated with DAR and biofilm-active antibiotics was predictive of adverse QOL outcomes. Results: Of 20 patients with staphylococcal PJI, treatment failure occurred in two patients. The cumulative risk of treatment failure after 1 year was 11.76% (95% CI 3.08–39.40%). Ten of 11 patients with infections involving methicillin-resistant Staphylococcus aureus had successful outcomes. Of 17 patients with Gram-negative bacillus PJI, treatment failure occurred in two patients. In only one patient was a relapsed Gram-negative infection responsible for the failure and this patient had not been treated with ciprofloxacin. The 2-year survival rate free of treatment failure was 94% (95% CI, 63–99%). In 19 hip PJI cases there was significant improvement 12-months post-arthroplasty in function according to Harris Hip Score and QOL according to the 12-item Short Form Health Survey Physical Component Summary. There was no significant difference in the improvement between 76 controls and the 19 cases. Medical complications occurred more frequently in cases than controls but the rate of surgical complications was the same. Of 2134 patients in a hip and knee arthroplasty cohort there were 37 patients with PJI treated with DAR and biofilm-active antibiotics. On multivariate logistic analysis, PJI treated this way was not predictive of adverse QOL outcomes according to SF-12 scores, however pre-arthroplasty SF-12, female gender, knee arthroplasty and a comorbidity index were. Conclusions: DAR in combination with rifampicin and fusidic acid is effective and should be considered for patients with early staphylococcal PJI, including those with infections involving fluoroquinolone-resistant organisms. DAR in combination with ciprofloxacin is effective for patients with early Gram-negative bacillus prosthetic joint infection. Treatment of PJI with DAR and biofilm-active antibiotics was well tolerated and results in good improvements in function and QOL